Medi-Cal appeal process
Federal 42 CFR Part 438 Subpart F applies in every state. California-specific timelines and program info below.
How Medi-Cal appeals work
California Medicaid runs through a managed-care delivery system (MCO, PIHP, or PAHP). When the plan denies, reduces, or terminates a service you believe should be covered, you have appeal rights under federal law (42 CFR Part 438 Subpart F) plus any state-specific additions.
Three-step process
- Internal MCO appeal. File within 60 days of the adverse benefit determination. MCO has 30 days to decide for standard appeals, 72 hours for expedited.
- State Fair Hearing. If the MCO upholds the denial, request a hearing with the California Medicaid agency within 120 days. An Administrative Law Judge reviews the case and issues a binding decision.
- Continue benefits during appeal. Request "aid paid pending" within 10 days of the notice of action — services continue at the prior level until the appeal is resolved.
California contact
California Independent Medical Review (IMR) is available as a separate track in addition to State Fair Hearing — one of the strongest external-review processes in the country.
Frequently asked questions
How do I appeal a Medi-Cal denial?
File internal appeal with your Medicaid managed-care plan (MCO) within 60 days of the adverse benefit determination. The MCO has 30 days to decide (72 hours expedited). If the MCO upholds the denial, request a California State Fair Hearing within 120 days of the MCO's final appeal decision. The State Fair Hearing is conducted by an Administrative Law Judge and is binding on the MCO.
Can I keep my services during the appeal?
Yes — federal law (42 CFR §438.420) requires the MCO to continue services at the previously authorized level during the appeal IF you request continuation within 10 days of the notice of action. Mark "continue benefits" or "aid paid pending" on your appeal request to invoke this protection.
What if the MCO doesn't respond?
If the MCO misses any appeal deadline, you can go directly to State Fair Hearing without exhausting internal appeal. Document the missed deadline carefully.
What's specific to California?
California Independent Medical Review (IMR) is available as a separate track in addition to State Fair Hearing — one of the strongest external-review processes in the country.
Other California resources
Sources
Appeal your Medi-Cal denial
DenialHelp drafts the appeal letter in about five minutes — citing the federal 42 CFR Part 438 Subpart F regulation, the California state-specific deadlines, and the clinical guideline supporting your treatment.
Get started →Contact: hello@denialhelp.com